Nicardipine

Cardene

Dihydropyridine calcium channel blocker (vascular-selective)

Selective L-type voltage-gated calcium channel blocker, dihydropyridine class (vascular >> cardiac selectivity). Vascular smooth muscle relaxation → arterial vasodilation → afterload reduction. Minimal direct cardiac inotropic or chronotropic effect at clinical doses (vs verapamil/diltiazem which are non-selective).

Indications

•Acute hypertension management — perioperative HTN, hypertensive emergency, post-CV surgery
•Acute aortic dissection (after beta-blocker)
•Pulmonary hypertension acute management (some evidence)
•Cerebral vasospasm prophylaxis (subarachnoid hemorrhage — nimodipine PO preferred for cerebral)

Dosing

Context	Adult	Pediatric
Acute HTN bolus	0.5-1 mg IV q5min titrated; or 5 mg IV bolus	—
Continuous infusion	5-15 mg/h IV titrated to target BP (typical 10-15 mg/h)	—
Aortic dissection (after beta-blocker)	5-15 mg/h IV titrated to SBP <120	—

Pharmacokinetics

Onset 5-15 min IV bolus; 30-60 min infusion to peak. Duration 30-60 min after stopping infusion (longer than nitroglycerin). Hepatic metabolism via CYP3A4 (drug interactions). Half-life 2-4 h with linear kinetics. Active metabolite minimal.

Hemodynamic effects

↓SVR → ↓BP via afterload reduction. Reflex tachycardia (modest, usually 5-10 bpm). Minimal effect on contractility, conduction, or HR direct effects. Does NOT cause aortic dissection extension (in contrast to pure vasodilators that drop SVR rapidly without HR control).

Side effects

!Hypotension (additive with anesthetics)
!Reflex tachycardia
!Headache, flushing (vasodilation)
!Phlebitis at infusion site (peripheral OK; central preferred for sustained infusion)
!Nausea/vomiting

Contraindications

×Severe aortic stenosis (afterload reduction increases gradient + decreases coronary perfusion pressure)
×Acute MI with hypotension
×Hypersensitivity

Clinical pearls

★PREFERRED FIRST-LINE for intraop HTN in non-cardiac surgery — easier to titrate than nitroprusside (no cyanide), no rebound tachycardia of nitroglycerin, longer duration than esmolol.
★Combine with esmolol or labetalol for tachycardia + HTN (ESMOLOL FIRST in dissection — esmolol prevents reflex tachy).
★INFUSION PUMP titration: typical adult 5 mg/h start, increase by 2.5 mg/h q5-15 min until target. Once at target, titrate downward as anesthetic stabilizes.
★Cerebral effects: causes mild cerebral vasodilation (may raise ICP transiently); use cautiously in elevated ICP — but blood pressure control + cerebral perfusion preservation usually outweighs.
★Switch to oral antihypertensive (amlodipine, labetalol PO) before stopping infusion — some patients have rebound HTN.